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U.S.

Department of State Approved OMB 1405-0226


Expires 11/30/2017
Estimated Burden 60 Minutes
SUPPLEMENTAL QUESTIONS FOR VISA APPLICANTS

General Instructions

If youare unsure ofthe answer to a question, please provide a response to the best of yourknowledge. For example, ifyou are unsure of an exact address,
provide the city, state, and street name ifyou can recall them. U.S. Department of State will consider allthe information derived from the form in its entirety.
Failureto answer every question will not necessarily preclude visa issuance, as the application is considered in its entirety.
Ifyou believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A."
Ifyou need more space to respond to a question, please write the rest of your response on a separate sheet of paper.
Personal Information

Surname(s) Given Name(s)

Date of Birth (mm-dd-yyyy) Visa Type/Classification

Passport and Travel History


Have you travelled to any country (otherthan yourcountry of residence) in the last 15 years? Yes No
Ifyes, provide details for each trip, including locations visited, date visited, source of funds, and length of stay.

Have you ever held a passport other than the passport listed in your visa application? Yes No
Ifyes, provide the following information.

Country of Issuance Passport Number

Relatives

Siblings (brothers and sisters) - Provide the full name(s) and date of birth of any sibling (full, half, step, adopted), living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)

Children - Provide the full name(s) and date of birth of any child (minor and adult), living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)

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Relatives - Continued

Spouse - Provide the full name(s) of any current or previousspouse or civil/domestic partner, living or deceased.
Surname(s) Given Name(s) Date of Birth (mm-dd-yyyy)

Address and Contact Information

Address - Provide all addresses where you have lived during the last 15 years, if not already provided in your application.
Address 1 Address 2
Dates of Residence (mm-dd-yyyy) Dates of Residence (mm-dd-yyyy)

Street Address 1 Street Address 1

Street Address 2 Street Address 2

City State/Province City State/Province

Postal Zone/Zip Code Country/Region Postal Zone/Zip Code Country/Region

Phone Number - Provide all phone numbers you have used in the last five years, including primary, secondary, work, home, and mobile numbers.
Phone Number (1) Phone Number (2) Phone Number (3) Phone Number (4)

Phone Number (5) Phone Number (6) Phone Number (7) Phone Number (8)

E-mail - Provide all email addresses you have used in the last five years, including primary, secondary, work, personal, and educational addresses.
E-mail Address (1) E-mail Address (2)

E-mail Address (3) E-mail Address (4)

E-mail Address (5) E-mail Address (6)

Social Media

Please provide your unique user name for any websites or applications you have used to create or share content (photos, videos, status updates, etc.) as part of
a public profile within the last five years.

Social Media Platform Social Media Identifier (Name/Handle)

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Provide the following information on all employers in the last fifteen years, if not already provided in your application.
Employer Name Employer Name

Dates ofEmployment (mm-dd-yyyy) Dates of Employment (mm-dd-yyyy)

Street Address 1 Street Address 1

Street Address 2 Street Address 2

City State/Province City State/Province

Postal Zone/Zip Code Country/Region Postal Zone/Zip Code Country/Region

Telephone Number Telephone Number

Job Title Job Title

Job Description Job Description

The information provided in this application and other information submitted may be provided to other U.S. government agencies having statutory or other lawful
authority to use such information, including for law enforcement and immigration law enforcement purposes. I understand that any willfully false or misleading
statement or willful concealment of a material fact made by me herein may subject me to permanent exclusion from the United States and, if I am admitted to the
United States, may subject me to criminal prosecution and/or removal.
Applicant's Signature Date (mm-dd-yyyy)

For use by United States embassy or consulate official only: DS-160/DS-260 Barcode Number

PAPERWORK REDUCTION ACT STATEMENT

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time required for searching existing data
sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to
supply this information unless this collection displays a currently valid OMB control number. Ifyou have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: PRA_BurdenComments@state.gov.

CONFIDENTIALITY STATEMENT

AUTHORITIES: The information on this form is requested pursuant to Section 212(a) and 221 and as required by Section 222 of the Immigration and Nationality
Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance and
refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or
enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may, in the discretion of the Secretary of State,
be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court.

PURPOSE: The U.S. Department of State uses the information provided on this form to determine an individual's eligibility for a U.S. visa. Individuals who fail to
submit this form or who do not provide all the requested information may be denied a U.S. visa. Although furnishing this information is voluntary, failure to
provide this information may delay or prevent the processing of an individual visa application.

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